21/03/2013

Life Threatening
Arrhythmias
Frances Lin

Prerequisites and objectives of this

lecture

ECG basics lecture

Identify and interpret life threatening
arrhythmias.
Learn skills to manage patients with life
threatening arrhythmias.

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Ventricular Rhythms

Premature Ventricular Contractions (PVC's)

Ventricular Fibrillation (VF)
Ventricular tachycardia (V-tach)
Torsades des pointes

Premature Ventricular Contractions

(PVC's)

Early or premature ventricular beats in the ECG

rhythm strip.
The 'QRS' complex of the early beat:

Wide and bizarre.

QRS duration >0 .12sec.

Usually no 'P' wave precede the 'QRS' complex of the

PVC.
PVC's usually have compensatory pauses.
Patterns of PVC's

Bigeminy pattern in which every second beat is a PVC.

Trigeminy pattern in which every third beat is a PVC.

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PVCs

http://www.mededsys-nurse.com/courses_online/203/203.html

Bigeminy

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Trigeminy

Ventricular Ectopic Beats (VEBs)

They must occur at the end of a pause.

The 'QRS' complex of this late beat must be
>0.12sec.
3. No 'P' wave will precede the ventricular beat
(QRS complex).

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Significance of PVC and VEB

Single beats often benign.

New appearance and increased frequency, with
cardiac or systemic disease may precede more
serious arrhythmias.
Close monitoring
Look for underlying cause

Define life threathening

An arrhythmia which adversely affects

haemodynamics
Reduces cardiac output
Inability to sustain pulse and blood pressure

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Causes of Life Threatening Arrhythmias

Myocardial cell Ischaemia/Death

AMI
Hypoxia
Electrolyte Imbalance
Drug toxicity
Cardiomyopathy
Accessory conduction pathways

Ventricular Fibrillation (VF)

Rate

Atrial Cant be determined

Ventricular Cant be determined

Rhythm

Atrial Cant be determined

Ventricular Fibrillatory waves, irregular

P Wave

PR Interval

QRS Complex

QT Interval

Cant be determined
Cant be determined
Cant be determined
Not measurable

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Ventricular Fibrillation (VF)

Complete breakdown of all rhythm

a) coarse
b) fine

Shockable

The patient in VF

Pulseless
Unconscious
What do you do immediately? (think ALS)

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Management of VF

Defibrillation
IV Adrenaline
IV Amiodarone
IV Lignocaine

Ventricular Tachycardia (VT, V Tach)

Rate

Rhythm

Atrial cant be determined

Ventricular - > 100/min
Atrial cant be determined
Ventricular regular, but may be irregular

P Waves

Usually absent
Impulse originates in the ventricle

PR Interval

QRS Complex

Not measurable
Duration (wide) Exceeds 0.12 second
Bizarre increased amplitude
Monomorphic uniform
Polymorphic changes shape

QT Interval

Not measureable

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VT ECG

The patient in VT

Can be
With pulse (what does my patient look like)
pulseless (shockable)

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Treatment of VT

Stable with Cardiac output

IV Amiodarone
IV Adenosine
Pacing

Pulseless VT

Defibrillation
CPR
IV Adrenaline
IV Amiodarone
IV Lignocaine

Torsades des pointes

A rapid ventricular rhythm

QRS polymorphic (positive and negative coexists)
Q-T can be prolonged
The rate is a variable 250 to 350 per minute, in brief episodes.
Bradycardia or pauses immediately preceding onset
Self limiting but can be recurrent
Causes:

Hypokalaemia,
Medications (those that block potassium channels),
Congenital abnormalities (e.g., Long QT Syndrome) that lengthen the QT
interval.

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http://www.themdsite.com/physicians.cfm

Torsades des pointes

Treatment

Cease Q-T prolonging agents.

Same as Ventricular arrhythmia management:
prevent bradycardia
Isoprenaline
Pacing

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Asystole

Rate

Atrial Not present

Ventricular Not present

Rhythm

Atrial Not present

Ventricular Not present

P Wave

PR Interval

QRS Complex

Not present
No measurable
Absent or occasional escape
QT Interval
No measurable

Asystole

Pulseless
Not shockable

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Treatment of Asystole

Cardiopulmonary Resuscitation
IV Adrenaline
IV Atropine

Electromechanical Dissociation (EMD)/Pulseless

Electrical Activity (PEA)

Presence of a coordinated electrical rhythm that you

would expect to be a perfusing rhythm. No Cardiac
output.
Causes

Pericardial tamponade
Hypoxia/Acidosis
Electrolyte imbalance
Tension Pneumothorax
Hypovolaemia
Pulmonary embolus

Non-shockable

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Treatment of EMD/PEA

Same as asystole

The ECG dance: ECG can be fun!

http://kingmagic.wordpress.com/2009/06/17/t
he-ecg-through-the-medium-of-dance/

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